Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation.
Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation.
复制标题
DOI：
10.1161/circulationaha.116.023309
复制
发表时间：
2016-12-20
期刊：
影响因子：
37.8
通讯作者：
Callaway CW
中科院分区：
文献类型：
--
作者：
Reynolds JC;Grunau BE;Rittenberger JC;Sawyer KN;Kurz MC;Callaway CW
很少有证据指导院外心脏骤停（OHCA）中适当的复苏时间，而且证明更长或更短持续时间的病例特征也不明确。我们使用一个大型、多中心队列来估计复苏时间对OHCA患者良好功能结局概率的影响。一项北美单盲、多中心、集群随机临床试验（ROC-PRIMED）对连续成人非创伤性、ems治疗的OHCA进行了二次分析。主要暴露是复苏持续时间（以分钟为单位）（从专业复苏开始到自然循环恢复[ROSC]或复苏终止）。主要终点为存活至出院，预后良好（改良Rankin量表[mRS] 0-3）。另外，将受试者分为生存不良（mRS 4-5）、无生存ROSC （mRS 6）或无ROSC。受试者应计收益被绘制为复苏时间的函数，出院时对整个队列和亚组有利结果的动态概率进行估计。调整后的逻辑回归模型检验了复苏时间与预后良好的生存之间的关系。主要队列包括11,368名受试者（中位年龄69岁[IQR: 56-81岁]；男性7121名[62.6%]）。其中4023例（35.4%）达到ROSC， 1232例（10.8%）存活至出院，905例（8.0%）出院时mRS为0-3。心肺复苏术持续时间的分布因转归而异（p<0.00001）。CPR持续时间达37.0分钟（95%CI 34.9-40.9分钟），出院时最终mRS 0-3的患者中99%达到ROSC。出院时mRS 0-3的动态概率随着复苏时间的延长而下降，但初始心律震荡、心脏骤停和旁观者CPR的受试者在延长努力（30-40分钟）后更有可能存活并获得良好结果。调整院前（OR 0.93; 95%CI 0.92-0.95）和住院（OR 0.97; 95%CI 0.95-0.99）协变量后，复苏时间与mRS 0-3的出院生存率相关。较短的复苏时间与出院时良好预后的可能性相关。具有良好病例特征的受试者更有可能在延长的复苏中存活至47分钟。
Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest (OHCA), and case features justifying longer or shorter durations are ill-defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in OHCA using a large, multi-center cohort. Secondary analysis of a North American, single blind, multi-center, cluster-randomized clinical trial (ROC-PRIMED) of consecutive adults with non-traumatic, EMS-treated, OHCA. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. The primary cohort included 11,368 subjects (median age 69 years [IQR: 56-81 years]; 7,121 men [62.6%]). Of these, 4,023 (35.4%) achieved ROSC, 1,232 (10.8%) survived to hospital discharge, and 905 (8.0%) had mRS 0-3 at discharge. Distribution of CPR duration differed by outcome (p<0.00001). For CPR duration up to 37.0 minutes (95%CI 34.9-40.9 minutes), 99% with eventual mRS 0-3 at discharge achieved ROSC. Dynamic probability of mRS 0-3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander CPR were more likely to survive with favorable outcome after prolonged efforts (30-40 minutes). Adjusting for prehospital (OR 0.93; 95%CI 0.92-0.95) and inpatient (OR 0.97; 95%CI 0.95-0.99) covariates, resuscitation duration was associated with survival to discharge with mRS 0-3. Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes.